mymontanasmiles.com - Patient Registration

PATIENT REGISTRATION
Patient's Full Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:
Relationship:
Emergency Contact Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status:
Spouse Full Name

First NameLast Name
Maiden Name:
If the Patient is a minor (under the age of 18), please provide information for the parent or legal guardian.
Parent/Legal Guardian Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE COMPANY
Insurance Company:
Group #:
ID # or SSN #:
Policy Holder’s Name:
Policy Holder’s DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holder’s Employer:
Relationship to Patient:
ALLERGIES
Are you allergic to any of the following?
Other Antibiotics - If yes, which ones?
Other Drugs – If yes, which ones?
I authorize Dr. Blanchard to perform any necessary dental work.
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Allergies:
Have you ever been hospitalized or had major operations?
Current Medications:
Are you pregnant?
If yes, due date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you use / drink:
How much / How often:

Do you have or have you had any of the following?

Rows	YES	NO
A-Fib
AIDS/HIV
Alzheimer’s Disease
Anaphylaxis
Anemia
Arthritis / Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Thinner
Blood Transfusion
Breathing Problems
Bruise Easily
Chemotherapy
Chest Pains
Cold Sores / Fever Blisters
Congenital Heart Disorder
Cortisone Medicine
Crohn's / Intestinal Disease / IBS
Diabetes
Drug / Alcohol Addiction
Emphysema
Epilepsy or Seizure
Excessive Bleeding
Excessive Thirst
Fainting Spells / Dizziness
Frequent Headaches
Heart Attack / Failure
Heart Murmur
Heart Pacemaker
Heart Trouble / Disease and More
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care / Mental Illness
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Sexually Transmitted Infection / Disease
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers

PATIENT REGISTRATION